The PulseFEB 2017 VOL 14.

a monthly newsletter for staff and friends ofGRANDE INTERNATIONAL HOSPITAL

w w w . g r a n d e h o s p i t a l . c o m

CIRRHOSISCUPID PACKAGE

DIARRHOEAL DISEASESPEPTIC ULCERS

DOCTOR’S VISIT DID YOU KNOW

4page

Dhapasi, Kathmandu, Nepal P.O. Box: 11796 T : 01-5159266, 5159267, 1618015159266 (Audio Notice)F : 977-1-5159276 E : info@grandehospital.com

www.grandehospi ta l .com

An in i t ia t ive by the Market ing & Business DevelopmentDepartment, Grande Internat ional Hospi ta l .

Did you know?

Liver is the second largest organ (approximately 1.5 kg) in the human body.

Liver performs over 500 functions including �ghting o� infection, neutralizing toxins and helping to clot the blood, and produces proteins.

At any time, liver contains about 10% of the blood in our body and pumps 1.4 litres per minute.

1 2

3

Liver is our battery. It stocks up sugar and when required, uses it avoiding any drastic fall in blood sugar level.5

Liver is the only organ that grows back (this makes it possible for people with normal liver to donate a part of it to another person with a diseased liver). 4

Professor Kwang-Woong Lee, Executive Director of International Healthcare Centre, Seol National University college of Medicine, Department of Surgery and Professor Young Rok Choi from Hepato Billiary Pancreas Division, Department of Surgery, Seol National University Bundang hospital visited Grande International Hospital in January 2017.

Professor Kwang-Woong Lee graduated from Seoul National University. He has been with Samsung Medical Center and National Cancer Center, Korea as a hepatic and transplant surgeon. He has also been in Johns Hopkins University Hospital as a LDLT consultant. He is an executive of international health care center and a professor of department of surgery, Seoul National University, Korea.

He performed the �rst successful hepato cyte transplantation in Korea when he was in Samsung Medical Center. His research topics are hepatocyte transplantation, gene delivery, cancer stem cell, best immunosuppressant for HCC, bile duct ischemia induced by warm ischemia,

Dr. Prakash Karki (MD, FHM) Regional Medical Director, EmCare North Division, USA – Visited Grande International Hospital.

He presented 'An overview of US healthcare delivery, how it a�ects hospitals and how they function, and discussion of publicly reported measures.' In the specially organized continuing medical education.

Doctors, medical sta� and administrators from Grande International Hospital participated in that interactive CME held in the conference hall at second �oor.

e d i t o r i a l

Frost & Sul l ivan 2016 Nepal

Grande International Hospital received the

2016 award from Frost & Sullivan.

‘Hospital of the Year’

01-5159266, 5159267For further information and appointments

Dr. Sushil Pandey, Colorectal Surgeon visited Grande International Hospital on 26th of December 2016.

Dr. Pandey has graduated from Monte�ore Medical Center, New York and he is currently associated with institute of Colon & Rectal Surgery, Chicago, USA.

GIH felicitated the esteemed surgeon Dr. Sushil Pandey for his valuable speech on the CME to help us taking the Department of GI Surgery at GIH to the next level.

polymorphism and so on. He developed several innovative techniques to reduce biliary complications a�er liver transplantation such as high hilar dissection (HHD) and Tailored Telesco pic Reconstruction (TTR) of bile duct.

He also played an important role to change deceased donor allocation system in Korea (split liver transplantation regulation and Deceased donor allocation system based on MELD) by publishing several important papers analyzing Korean database. He performed �rst living donor liver transplantation for pure foreign patients in Korea when he was in National Cancer Center, Korea. He has performed more than 40 cases of LDLT in Kazakhstan and Georgia since 2013.

Professor Young Rok Choi graduated from Seoul National University. He has been with Samsung Medical Center and National Cancer Center, Korea as a hepatic and transplant surgeon. He was one of the member of the �rst successful hepato cyte transplantation in Korea when he was in Samsung Medical Center.

WORLD RENOWNED LIVER TRANSPLANTSURGEON FROM KOREA VISITS GIH

P a c k a g e i n c l u d e s

Doctors Consultat ion CBC Blood Sugar (F) L ipid Profile TSH Creat inine SGPT Ur ic Acid Ur ine (R)

Chest X-Ray USG Abdomen & Pelvis ECG ECHO TMT or BMD Breakfast & Hospital Registrat ion Card

This Valentine’s Day buy The Cupid Package

for Rs.13,000 and get one free for your partner.

Offer valid from 14 - 21 Feb w w w . g r a n d e h o s p i t a l . c o m

HOW WELL DO YOUKNOW YOUR

?

Prime Ministervisits GIH

�is issue of �e Pulse focuses on Gastroenterology. Diseases like diaorrhea, peptic ulcers & cirrhosis are common in Nepal. With a team of well-trained doctors and state-of-the-art equipment, Grande International Hospital has been able to achieve excellent clinical outcomes. A dedicated department for endoscopy allows for procedures to be done without delay so patients can feel relaxed and comfortable.

DR PRAKASH KARKI FROMINDIANA, USA ON US HEALTHCARE SYSTEM

DIGESTIVE DISEASESEXPERT SURGEON FROM CHICAGO, USA

�e Rt. Hon. Prime Minister Pushpa Kamal Dahal with the Medical Director of GIH, Dr Chakra Raj Pandey, Gastroenterologist Dr Vivek Sharma and Nursing Director LD Maharjan

WORKSHOP ON INFECTION CONTROL HELD AT GIHRecently concluded a one day workshop on infection control that was jointly organized by GIH, Critical Care Nurses Association; ASK foundation and Critical Care Development Foundation.

100 nurses and clinical sta� members from di�erent hospitals were present in the workshop.

The PulseFEB 2017 VOL 14.

a monthly newsletter for staff and friends ofGRANDE INTERNATIONAL HOSPITAL

w w w . g r a n d e h o s p i t a l . c o m

CIRRHOSISCUPID PACKAGE

DIARRHOEAL DISEASESPEPTIC ULCERS

DOCTOR’S VISIT DID YOU KNOW

4page

Dhapasi, Kathmandu, Nepal P.O. Box: 11796 T : 01-5159266, 5159267, 1618015159266 (Audio Notice)F : 977-1-5159276 E : info@grandehospital.com

www.grandehospi ta l .com

An in i t ia t ive by the Market ing & Business DevelopmentDepartment, Grande Internat ional Hospi ta l .

Did you know?

Liver is the second largest organ (approximately 1.5 kg) in the human body.

Liver performs over 500 functions including �ghting o� infection, neutralizing toxins and helping to clot the blood, and produces proteins.

At any time, liver contains about 10% of the blood in our body and pumps 1.4 litres per minute.

1 2

3

Liver is our battery. It stocks up sugar and when required, uses it avoiding any drastic fall in blood sugar level.5

Liver is the only organ that grows back (this makes it possible for people with normal liver to donate a part of it to another person with a diseased liver). 4

Professor Kwang-Woong Lee, Executive Director of International Healthcare Centre, Seol National University college of Medicine, Department of Surgery and Professor Young Rok Choi from Hepato Billiary Pancreas Division, Department of Surgery, Seol National University Bundang hospital visited Grande International Hospital in January 2017.

Professor Kwang-Woong Lee graduated from Seoul National University. He has been with Samsung Medical Center and National Cancer Center, Korea as a hepatic and transplant surgeon. He has also been in Johns Hopkins University Hospital as a LDLT consultant. He is an executive of international health care center and a professor of department of surgery, Seoul National University, Korea.

He performed the �rst successful hepato cyte transplantation in Korea when he was in Samsung Medical Center. His research topics are hepatocyte transplantation, gene delivery, cancer stem cell, best immunosuppressant for HCC, bile duct ischemia induced by warm ischemia,

Dr. Prakash Karki (MD, FHM) Regional Medical Director, EmCare North Division, USA – Visited Grande International Hospital.

He presented 'An overview of US healthcare delivery, how it a�ects hospitals and how they function, and discussion of publicly reported measures.' In the specially organized continuing medical education.

Doctors, medical sta� and administrators from Grande International Hospital participated in that interactive CME held in the conference hall at second �oor.

e d i t o r i a l

Frost & Sul l ivan 2016 Nepal

Grande International Hospital received the

2016 award from Frost & Sullivan.

‘Hospital of the Year’

01-5159266, 5159267For further information and appointments

Dr. Sushil Pandey, Colorectal Surgeon visited Grande International Hospital on 26th of December 2016.

Dr. Pandey has graduated from Monte�ore Medical Center, New York and he is currently associated with institute of Colon & Rectal Surgery, Chicago, USA.

GIH felicitated the esteemed surgeon Dr. Sushil Pandey for his valuable speech on the CME to help us taking the Department of GI Surgery at GIH to the next level.

polymorphism and so on. He developed several innovative techniques to reduce biliary complications a�er liver transplantation such as high hilar dissection (HHD) and Tailored Telesco pic Reconstruction (TTR) of bile duct.

He also played an important role to change deceased donor allocation system in Korea (split liver transplantation regulation and Deceased donor allocation system based on MELD) by publishing several important papers analyzing Korean database. He performed �rst living donor liver transplantation for pure foreign patients in Korea when he was in National Cancer Center, Korea. He has performed more than 40 cases of LDLT in Kazakhstan and Georgia since 2013.

Professor Young Rok Choi graduated from Seoul National University. He has been with Samsung Medical Center and National Cancer Center, Korea as a hepatic and transplant surgeon. He was one of the member of the �rst successful hepato cyte transplantation in Korea when he was in Samsung Medical Center.

WORLD RENOWNED LIVER TRANSPLANTSURGEON FROM KOREA VISITS GIH

P a c k a g e i n c l u d e s

Doctors Consultat ion CBC Blood Sugar (F) L ipid Profile TSH Creat inine SGPT Ur ic Acid Ur ine (R)

Chest X-Ray USG Abdomen & Pelvis ECG ECHO TMT or BMD Breakfast & Hospital Registrat ion Card

This Valentine’s Day buy The Cupid Package

for Rs.13,000 and get one free for your partner.

Offer valid from 14 - 21 Feb w w w . g r a n d e h o s p i t a l . c o m

HOW WELL DO YOUKNOW YOUR

?

Prime Ministervisits GIH

�is issue of �e Pulse focuses on Gastroenterology. Diseases like diaorrhea, peptic ulcers & cirrhosis are common in Nepal. With a team of well-trained doctors and state-of-the-art equipment, Grande International Hospital has been able to achieve excellent clinical outcomes. A dedicated department for endoscopy allows for procedures to be done without delay so patients can feel relaxed and comfortable.

DR PRAKASH KARKI FROMINDIANA, USA ON US HEALTHCARE SYSTEM

DIGESTIVE DISEASESEXPERT SURGEON FROM CHICAGO, USA

�e Rt. Hon. Prime Minister Pushpa Kamal Dahal with the Medical Director of GIH, Dr Chakra Raj Pandey, Gastroenterologist Dr Vivek Sharma and Nursing Director LD Maharjan

WORKSHOP ON INFECTION CONTROL HELD AT GIHRecently concluded a one day workshop on infection control that was jointly organized by GIH, Critical Care Nurses Association; ASK foundation and Critical Care Development Foundation.

100 nurses and clinical sta� members from di�erent hospitals were present in the workshop.

2page 3page

Diarrhoeal diseases are the leading cause of death in developing countries. Death of diarrhoeal diseases is usually from severe dehydration and �uid loss. Children under �ve, malnourished or have impaired immunity (HIV, Tuberculosis, Cancer) are more a�ected.

�ere are three types of Diarrhoea• Acute diarrhoea - lasts several hours or days.• Chronic diarrhoea - lasts two weeks or longer.• Factitious diarrhoea – commonly seen in females due to high dose of purgatives.

Cause of diarrhoeal disease• Most common cause of diarrhoea is due to infections like rotavirus, e-coli, shigella, salmonella, entamoeba histolytica and giardia.• Travelers diarrhoea which affects people travelling to developing countries.• Cause of chronic diarrhoea like, inflammatory bowel disease, carcinoma, thyroid problem, allergy to milk products,

Dr. Vivek Sharma

What is a Peptic ulcer?Peptic ulcers are painful sores that can be found in the stomach lining or small intestine. Stomach ulcers are the most visible sign of peptic ulcer disease. �ey occur when the thick layer of mucus that protects your stomach from digestive juices is reduced, thus enabling the digestive acids to eat away at the lining tissues of the stomach.Stomach ulcers are easily cured, but they can become severe without proper treatment.

What causes stomach ulcers?Stomach ulcers aren’t necessarily caused by one single factor. �e decrease in the stomach’s mucus lining that leads to an ulcer is usually caused by one of the following:• An infection with the bacterium Helicobacter pylori (H. pylori)• Long-term use of nonsteroidal anti-inflammatory drugs (NSAIDs), such as aspirin and ibuprofen• Excess acid (hyperacidity) in the stomach, which may be related to genetics,

Dr. Akhilesh Kumar KasyapConsultant Gastroenterologist

PEPTIC ULCERSC I R R H O S I S

D I A R R H O E A L D I S E A S E Swheat, oats and gastroenterology infection.Signs and symptoms• Fever• Blood in stool• Abdominal pain• Vomiting• If severe – diarrhoea can be a problem.�e most severe threat by diarrhoea is as follows

1. Mild dehydration - no signs or symptoms can be thirsty.• Irritable

2. Moderate dehydration• Thirsty• Irritable• Weak pulse• Sunken eyes• Decreased skin elasticity

3. Severe dehydration• Symptoms become more severe• Shock with diminished consciousness, decreased urine output, feeble pulse, decreased blood pressure.

Prevention and managementKey Measures• Access to safe drinking water• Use of improved sanitations• Hand washing• Good personal and food hygiene• Health education• Vaccination

Investigations• Stool examination• Blood count• Kidney functions test• Colonoscopy or sigmoidoscopy and biopsy.

• Other investigations according to cause.

Key measures to treat diarrhoea include the following:

• Rehydration with oral rehydration salt solution in mild / moderate dehydration.• Rehydration with intravenous fluids in case of severe dehydration or shock.• Nutrient rich foods.• Zink supplements.• Antibiotics and other treatment according to cause of diarrhoea.• Treatment according to colonoscopy, sigmoidoscopy with biopsy repeat in chronic diarrhoea.Key Facts• Diarrhoeal disease is leading cause of death in developing country, it is preventable and treatable.• A significant proportion of diarrhoeal disease can be prevented through safe drinking water and adequate sanitation and hygiene.• Young children and very old are more susceptible to dehydration.• Diarrhoea is a leading cause of malnutrition in children under �ve years old.

lifestyle (stress, smoking), and certain foods• Zollinger-Ellison syndrome, a rare disease that makes the body produce excess stomach acidCertain factors and behaviors can put you at higher risk for developing stomach ulcers:• Smoking• Frequent use of steroids (such as those for treating asthma)• Hypercalcemia (overproduction of calcium)• Family history of stomach ulcers• Being over 50 years old• Excessive consumption of alcohol

Symptoms of stomach ulcersA number of symptoms are associated with stomach ulcers. �e severity of the symptoms depends on the severity of the ulcer.�e most common symptom is a burning sensation or pain in the area between your chest and belly button. Normally, the pain will be more intense when your stomach is empty and it can last for a few minutes or several hours.Other common symptoms include:• Dull pain in the stomach• Weight loss• Not wanting to eat because of pain• Nausea or vomiting• Bloating• Burping or acid reflux• Heartburn (burning sensation in the chest)• Pain improves when you eat, drink, or take antacidsTalk to your doctor if you experience symptoms of a stomach ulcer. Even though discomfort may be mild, ulcers can worsen if they aren’t treated.

How are stomach ulcers diagnosed?Diagnosis and treatment will depend on your symptoms and the severity of your ulcer. To diagnose a stomach ulcer, your doctor will review your medical history

along with your symptoms and any prescription or over-the-counter medications you’re taking.

• Endoscopy: a thin, lighted tube is inserted through the mouth and into the stomach to look for the presence of an ulcer• Endoscopic biopsy: a piece of stomach tissue is removed so it can be analyzed

Treating stomach ulcersTreatment will vary depending on the cause of your ulcer. Most ulcers can be treated with a prescription from your doctor, but in rare cases, surgery may be required.It’s important to promptly treat an ulcer. Talk to your doctor to discuss a treatment plan. If you have an actively bleeding ulcer, you’ll likely be hospitalized for intensive treatment with IV ulcer medications, and you may also require blood transfusion.

Nonsurgical treatmentIf your stomach ulcer is the result of H. pylori, you’ll need antibiotics. For mild to moderate stomach ulcers, your doctor will usually prescribe the following medications:• H2 blockers: to prevent your stomach from making too much acid• Proton pump inhibitors: blocks the cells that produce acid

• Over-the-counter antacids: to help neutralize stomach acid• Cytoprotective agents: to protect the l ining of the stomach and small intestine, such as Pepto-BismolDoctors will also suggest that you avoid smoking, alcohol, and any medications or foods that can trigger symptoms.

Surgical treatmentIn very rare cases, a complicated stomach ulcer will require surgery.

Complications associated with stomach ulcersSeek treatment as soon as you believe that you might have a stomach ulcer. �e longer an ulcer remains untreated, the more likely you are to develop complications. You should seek medical treatment if you experience any of the following symptoms:• Sudden, sharp pain that doesn’t stop• Black or bloody stools• Bloody vomitus• Vomit that looks like coffee grounds

Prevention of stomach ulcersTo prevent the spread of bacteria and reduce risk of bacterial infection, wash your hands with soap and water on a regular basis. Make sure all food is properly cleaned and cooked

thoroughly.To prevent ulcers caused by NSAIDs, stop using these medications (if possible) or limit their use. If you need to take NSAIDs, be sure to follow the recommended dosage and avoid alcohol while taking these medications.Certain lifestyle changes can also help prevent ulcers from forming. Limiting alcohol consumption, avoiding tobacco products, and properly managing stress can all contribute to a healthy stomach lining.

Cirrhosis of the Liver: Causes, Symptoms and TreatmentsCirrhosis is an abnormal liver condition in which there is irreversible scarring of the liver. Cirrhosis is a progressive disease, developing slowly over many years, until eventually it can stop liver function (liver failure).

Causes of cirrhosisCommon causes of cirrhosis are long-term alcohol abuse, hepatitis B and C infection, and fatty liver disease. Of those, hepatitis B and C together are said to be the leading cause of cirrhosis (WHO).

Overconsumption of alcoholAccording to the NHS (National Health Service), UK, excessive alcohol consumption is when a man drinks more than 21 units and a woman drinks more than 14 units per week. Alcohol is one of the leading causes of liver cirrhosis. Heavy, regular, long-term drinkers are much more likely to develop cirrhosis, compared to other healthy people. Typically, heavy drinking needs to be sustained for at least ten years for cirrhosis to develop. �e period varies according to each individual.Regular heavy female drinkers are more

Consultant, Gastroenterologist, �erapeutic Endoscopist & Hepatologist

Dr. Vivek Sharma

likely to develop symptoms compared to men who consume the same amount.Heavy drinkers will eventually develop fatty liver. 20% to 30% of those who continue drinking heavily will develop alcoholic hepatitis, the next stage. Approximately 10% of heavy drinkers will subsequently develop cirrhosis - the third stage of alcoholic liver disease.

HepatitisHepatitis C, hepatitis B and D may cause cirrhosis of liver. Non-alcoholic steatohepatitis (NASH). NASH is more likely to occur with people who are obese, diabetes patients, those with high blood lipid (fat) levels, as well as individuals with hypertension (high blood pressure). NASH, in its early stages, begins with the accumulation of too much fat in the liver. �e fat causes in�ammation and scarring, resulting in possible cirrhosis later on.Autoimmune hepatitisThe person's own immune system attacks healthy organs in the body as though they were foreign substances. Sometimes the liver is attacked. Eventually the patient can develop cirrhosis.

Some genetic conditions Hemochromatosis - iron accumulates in the liver and other parts of the body. Wilson's disease - copper accumulates in the liver and other parts of the body.

Other diseases and conditionsSome of the other diseases and conditions that can contribute to cirrhosis are: Cystic �brosis Primary sclerosing cholangitis - hardening and scarring of the bile ducts

Galactosemia - inability to process sugars in milk Schistosomiasis - a parasite commonly found in some developing countries Biliary atresia - badly formed bile ducts in babies Glycogen storage disease - problems in the storage and energy release vital for cell function.

Symptoms of cirrhosisThe following signs and symptoms may occur: Blood capillaries become visible on the skin on the upper abdomen Fatigue Insomnia Itchy skin Loss of appetite Loss of bodyweight Nausea Pain or tenderness in the area where the liver is located Red or blotchy palms Weakness.The following signs and symptoms may appear as liver cirrhosis progresses: Abdomen fills up with fluid, giving the patient a large tummy (ascites)

Accelerated heartbeat Altered personality (as blood toxins build up and a�ect the brain) Bleeding gums Body and upper arms lose mass Body finds it harder to process alcohol Body finds it harder to process drugs Confusion Dizziness Fluid buildup on ankles, feet and legs (edema) Hair loss Higher susceptibility to bruising Jaundice (yellowing of the skin, whites of the eyes, and tongue) Loss of libido (sex drive) Memory problems More frequent fevers (susceptibility to infections) Muscle cramps Nosebleeds Pain on the right shoulder Panting (breathlessness) Stools become black and tarry, or very pale Urine becomes darker Vomiting blood Walking problems (staggering).

Diagnosis of cirrhosisThe following tests may also be ordered:A blood test - to measure how well the liver is functioning and determine whether there

is any damage. If levels of ALT (alanine transaminase) are high the patient may have hepatitis. Imaging tests - CT (computerized tomography), or MRI (magnetic resonance imaging) scan of the liver, Fibro scan.A biopsy – may help in diagnosis of cirrhosis.Endoscopy - The doctor sees the inside of the stomach on a screen, and looks out for swollen blood vessels (varices); a hallmark sign of cirrhosis.

Breathe test for early-stage liver disease steps closer

Treatments for cirrhosisIf the cirrhosis is diagnosed early enough, damage may be minimized by treating its underlying cause.Alcohol dependency (alcoholism) treatment - it is important for the patient to stop drinking if their cirrhosis was caused by long-term, regular heavy alcohol consumption. In many cases the doctor will recommend a treatment program for alcoholism.Medications - the patient may be prescribed drugs to control liver cell damage caused by hepatitis B or C.Treatment of swollen varices - if the patient vomits blood or passes bloody stools they probably have esophageal varices (in the food pipe). Urgent medical attention is required. The following procedures may help: Banding Injection sclerotherapy - A Sengstaken tube with a balloon TIPSS (transjugular intrahepatic portosystemic stent shunt) – Infections

Screening for liver cancer - patients with cirrhosis have a much higher risk of developing liver cancer. �e doctor may recommend regular blood tests and imaging scans.

Hepatic encephalopathy (high blood toxin levels) - drugs can help treat excessive blood toxin levels. The signs and symptoms need to be explained to the patient so that they know what to look out for.SBP – treated with antibiotics.Liver transplant - if the cirrhosis is advanced and there is liver failure (liver does not function) the patient may need a liver transplant.

Prevention of cirrhosisAlcohol - do not exceed the recommended daily/weekly alcohol limit. Men: maximum of 21 units per week, or three/four units per day Women: maximum of 14 units per week, or two/three units per dayIndividuals who have cirrhosis should abstain from alcohol completely. Alcohol accelerates the progression of the disease.

food that c leanse the l iver

2page 3page

Diarrhoeal diseases are the leading cause of death in developing countries. Death of diarrhoeal diseases is usually from severe dehydration and �uid loss. Children under �ve, malnourished or have impaired immunity (HIV, Tuberculosis, Cancer) are more a�ected.

�ere are three types of Diarrhoea• Acute diarrhoea - lasts several hours or days.• Chronic diarrhoea - lasts two weeks or longer.• Factitious diarrhoea – commonly seen in females due to high dose of purgatives.

Cause of diarrhoeal disease• Most common cause of diarrhoea is due to infections like rotavirus, e-coli, shigella, salmonella, entamoeba histolytica and giardia.• Travelers diarrhoea which affects people travelling to developing countries.• Cause of chronic diarrhoea like, inflammatory bowel disease, carcinoma, thyroid problem, allergy to milk products,

Dr. Vivek Sharma

What is a Peptic ulcer?Peptic ulcers are painful sores that can be found in the stomach lining or small intestine. Stomach ulcers are the most visible sign of peptic ulcer disease. �ey occur when the thick layer of mucus that protects your stomach from digestive juices is reduced, thus enabling the digestive acids to eat away at the lining tissues of the stomach.Stomach ulcers are easily cured, but they can become severe without proper treatment.

What causes stomach ulcers?Stomach ulcers aren’t necessarily caused by one single factor. �e decrease in the stomach’s mucus lining that leads to an ulcer is usually caused by one of the following:• An infection with the bacterium Helicobacter pylori (H. pylori)• Long-term use of nonsteroidal anti-inflammatory drugs (NSAIDs), such as aspirin and ibuprofen• Excess acid (hyperacidity) in the stomach, which may be related to genetics,

Dr. Akhilesh Kumar KasyapConsultant Gastroenterologist

PEPTIC ULCERSC I R R H O S I S

D I A R R H O E A L D I S E A S E Swheat, oats and gastroenterology infection.Signs and symptoms• Fever• Blood in stool• Abdominal pain• Vomiting• If severe – diarrhoea can be a problem.�e most severe threat by diarrhoea is as follows

1. Mild dehydration - no signs or symptoms can be thirsty.• Irritable

2. Moderate dehydration• Thirsty• Irritable• Weak pulse• Sunken eyes• Decreased skin elasticity

3. Severe dehydration• Symptoms become more severe• Shock with diminished consciousness, decreased urine output, feeble pulse, decreased blood pressure.

Prevention and managementKey Measures• Access to safe drinking water• Use of improved sanitations• Hand washing• Good personal and food hygiene• Health education• Vaccination

Investigations• Stool examination• Blood count• Kidney functions test• Colonoscopy or sigmoidoscopy and biopsy.

• Other investigations according to cause.

Key measures to treat diarrhoea include the following:

• Rehydration with oral rehydration salt solution in mild / moderate dehydration.• Rehydration with intravenous fluids in case of severe dehydration or shock.• Nutrient rich foods.• Zink supplements.• Antibiotics and other treatment according to cause of diarrhoea.• Treatment according to colonoscopy, sigmoidoscopy with biopsy repeat in chronic diarrhoea.Key Facts• Diarrhoeal disease is leading cause of death in developing country, it is preventable and treatable.• A significant proportion of diarrhoeal disease can be prevented through safe drinking water and adequate sanitation and hygiene.• Young children and very old are more susceptible to dehydration.• Diarrhoea is a leading cause of malnutrition in children under �ve years old.

lifestyle (stress, smoking), and certain foods• Zollinger-Ellison syndrome, a rare disease that makes the body produce excess stomach acidCertain factors and behaviors can put you at higher risk for developing stomach ulcers:• Smoking• Frequent use of steroids (such as those for treating asthma)• Hypercalcemia (overproduction of calcium)• Family history of stomach ulcers• Being over 50 years old• Excessive consumption of alcohol

Symptoms of stomach ulcersA number of symptoms are associated with stomach ulcers. �e severity of the symptoms depends on the severity of the ulcer.�e most common symptom is a burning sensation or pain in the area between your chest and belly button. Normally, the pain will be more intense when your stomach is empty and it can last for a few minutes or several hours.Other common symptoms include:• Dull pain in the stomach• Weight loss• Not wanting to eat because of pain• Nausea or vomiting• Bloating• Burping or acid reflux• Heartburn (burning sensation in the chest)• Pain improves when you eat, drink, or take antacidsTalk to your doctor if you experience symptoms of a stomach ulcer. Even though discomfort may be mild, ulcers can worsen if they aren’t treated.

How are stomach ulcers diagnosed?Diagnosis and treatment will depend on your symptoms and the severity of your ulcer. To diagnose a stomach ulcer, your doctor will review your medical history

along with your symptoms and any prescription or over-the-counter medications you’re taking.

• Endoscopy: a thin, lighted tube is inserted through the mouth and into the stomach to look for the presence of an ulcer• Endoscopic biopsy: a piece of stomach tissue is removed so it can be analyzed

Treating stomach ulcersTreatment will vary depending on the cause of your ulcer. Most ulcers can be treated with a prescription from your doctor, but in rare cases, surgery may be required.It’s important to promptly treat an ulcer. Talk to your doctor to discuss a treatment plan. If you have an actively bleeding ulcer, you’ll likely be hospitalized for intensive treatment with IV ulcer medications, and you may also require blood transfusion.

Nonsurgical treatmentIf your stomach ulcer is the result of H. pylori, you’ll need antibiotics. For mild to moderate stomach ulcers, your doctor will usually prescribe the following medications:• H2 blockers: to prevent your stomach from making too much acid• Proton pump inhibitors: blocks the cells that produce acid

• Over-the-counter antacids: to help neutralize stomach acid• Cytoprotective agents: to protect the l ining of the stomach and small intestine, such as Pepto-BismolDoctors will also suggest that you avoid smoking, alcohol, and any medications or foods that can trigger symptoms.

Surgical treatmentIn very rare cases, a complicated stomach ulcer will require surgery.

Complications associated with stomach ulcersSeek treatment as soon as you believe that you might have a stomach ulcer. �e longer an ulcer remains untreated, the more likely you are to develop complications. You should seek medical treatment if you experience any of the following symptoms:• Sudden, sharp pain that doesn’t stop• Black or bloody stools• Bloody vomitus• Vomit that looks like coffee grounds

Prevention of stomach ulcersTo prevent the spread of bacteria and reduce risk of bacterial infection, wash your hands with soap and water on a regular basis. Make sure all food is properly cleaned and cooked

thoroughly.To prevent ulcers caused by NSAIDs, stop using these medications (if possible) or limit their use. If you need to take NSAIDs, be sure to follow the recommended dosage and avoid alcohol while taking these medications.Certain lifestyle changes can also help prevent ulcers from forming. Limiting alcohol consumption, avoiding tobacco products, and properly managing stress can all contribute to a healthy stomach lining.

Cirrhosis of the Liver: Causes, Symptoms and TreatmentsCirrhosis is an abnormal liver condition in which there is irreversible scarring of the liver. Cirrhosis is a progressive disease, developing slowly over many years, until eventually it can stop liver function (liver failure).

Causes of cirrhosisCommon causes of cirrhosis are long-term alcohol abuse, hepatitis B and C infection, and fatty liver disease. Of those, hepatitis B and C together are said to be the leading cause of cirrhosis (WHO).

Overconsumption of alcoholAccording to the NHS (National Health Service), UK, excessive alcohol consumption is when a man drinks more than 21 units and a woman drinks more than 14 units per week. Alcohol is one of the leading causes of liver cirrhosis. Heavy, regular, long-term drinkers are much more likely to develop cirrhosis, compared to other healthy people. Typically, heavy drinking needs to be sustained for at least ten years for cirrhosis to develop. �e period varies according to each individual.Regular heavy female drinkers are more

Consultant, Gastroenterologist, �erapeutic Endoscopist & Hepatologist

Dr. Vivek Sharma

likely to develop symptoms compared to men who consume the same amount.Heavy drinkers will eventually develop fatty liver. 20% to 30% of those who continue drinking heavily will develop alcoholic hepatitis, the next stage. Approximately 10% of heavy drinkers will subsequently develop cirrhosis - the third stage of alcoholic liver disease.

HepatitisHepatitis C, hepatitis B and D may cause cirrhosis of liver. Non-alcoholic steatohepatitis (NASH). NASH is more likely to occur with people who are obese, diabetes patients, those with high blood lipid (fat) levels, as well as individuals with hypertension (high blood pressure). NASH, in its early stages, begins with the accumulation of too much fat in the liver. �e fat causes in�ammation and scarring, resulting in possible cirrhosis later on.Autoimmune hepatitisThe person's own immune system attacks healthy organs in the body as though they were foreign substances. Sometimes the liver is attacked. Eventually the patient can develop cirrhosis.

Some genetic conditions Hemochromatosis - iron accumulates in the liver and other parts of the body. Wilson's disease - copper accumulates in the liver and other parts of the body.

Other diseases and conditionsSome of the other diseases and conditions that can contribute to cirrhosis are: Cystic �brosis Primary sclerosing cholangitis - hardening and scarring of the bile ducts

Galactosemia - inability to process sugars in milk Schistosomiasis - a parasite commonly found in some developing countries Biliary atresia - badly formed bile ducts in babies Glycogen storage disease - problems in the storage and energy release vital for cell function.

Symptoms of cirrhosisThe following signs and symptoms may occur: Blood capillaries become visible on the skin on the upper abdomen Fatigue Insomnia Itchy skin Loss of appetite Loss of bodyweight Nausea Pain or tenderness in the area where the liver is located Red or blotchy palms Weakness.The following signs and symptoms may appear as liver cirrhosis progresses: Abdomen fills up with fluid, giving the patient a large tummy (ascites)

Accelerated heartbeat Altered personality (as blood toxins build up and a�ect the brain) Bleeding gums Body and upper arms lose mass Body finds it harder to process alcohol Body finds it harder to process drugs Confusion Dizziness Fluid buildup on ankles, feet and legs (edema) Hair loss Higher susceptibility to bruising Jaundice (yellowing of the skin, whites of the eyes, and tongue) Loss of libido (sex drive) Memory problems More frequent fevers (susceptibility to infections) Muscle cramps Nosebleeds Pain on the right shoulder Panting (breathlessness) Stools become black and tarry, or very pale Urine becomes darker Vomiting blood Walking problems (staggering).

Diagnosis of cirrhosisThe following tests may also be ordered:A blood test - to measure how well the liver is functioning and determine whether there

is any damage. If levels of ALT (alanine transaminase) are high the patient may have hepatitis. Imaging tests - CT (computerized tomography), or MRI (magnetic resonance imaging) scan of the liver, Fibro scan.A biopsy – may help in diagnosis of cirrhosis.Endoscopy - The doctor sees the inside of the stomach on a screen, and looks out for swollen blood vessels (varices); a hallmark sign of cirrhosis.

Breathe test for early-stage liver disease steps closer

Treatments for cirrhosisIf the cirrhosis is diagnosed early enough, damage may be minimized by treating its underlying cause.Alcohol dependency (alcoholism) treatment - it is important for the patient to stop drinking if their cirrhosis was caused by long-term, regular heavy alcohol consumption. In many cases the doctor will recommend a treatment program for alcoholism.Medications - the patient may be prescribed drugs to control liver cell damage caused by hepatitis B or C.Treatment of swollen varices - if the patient vomits blood or passes bloody stools they probably have esophageal varices (in the food pipe). Urgent medical attention is required. The following procedures may help: Banding Injection sclerotherapy - A Sengstaken tube with a balloon TIPSS (transjugular intrahepatic portosystemic stent shunt) – Infections

Screening for liver cancer - patients with cirrhosis have a much higher risk of developing liver cancer. �e doctor may recommend regular blood tests and imaging scans.

Hepatic encephalopathy (high blood toxin levels) - drugs can help treat excessive blood toxin levels. The signs and symptoms need to be explained to the patient so that they know what to look out for.SBP – treated with antibiotics.Liver transplant - if the cirrhosis is advanced and there is liver failure (liver does not function) the patient may need a liver transplant.

Prevention of cirrhosisAlcohol - do not exceed the recommended daily/weekly alcohol limit. Men: maximum of 21 units per week, or three/four units per day Women: maximum of 14 units per week, or two/three units per dayIndividuals who have cirrhosis should abstain from alcohol completely. Alcohol accelerates the progression of the disease.

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